GLOSSARY

HOW TO USE M.A.G.I.C.

ALPHABETICAL LIST OF ALL MEDICATIONS

 

A-E

F-J

 

K-O

 

P-T

U-Z

PROGRAM CAVEATS

&

FEDERAL POVERTY LIMIT CUTOFFS

PROGRAMS & MEDICATIONS BY DISEASE STATE/CONDITION

 

MIGRAINE

 

BLOOD THINNERS

 

AUTO-IMMUNE

 

 

CARDIOVASCULAR

 

 

DIABETES&INSULIN

INFECTIOUS DISEASE (ACUTE&HIV)

INHALERS (RESPIRATORY)

 

 

NEUROLOGY&PSYCHIATRY

 

ONCOLOGY

 

 

How to use MAGIC (document is interactive, clickable)

1. Find desired medication via alphabetical directory or medications by disease state/condition

a. TIP: Use CTRL + F to quickly search for medication

2. You will be directed to the manufacturer program eligibility criteria for the selected medication

 

ALPHABETICAL LIST OF ALL MEDICATIONS

A-E

Abilify Maintena (Aripiprazole) For Extended Release Injectable Suspension

Abraxane® (Paclitaxel Protein-Bound Particles For Injectable Suspension (Albumin-Bound))

Actemra (Tocilizumab)

Activase (Alteplase)

Acuvail (Ketorolac Tromethamine) Ophthalmic Solution

Adacel® (Tetanus Toxoid, Reduced Diphtheria Toxoid And Acellular Pertussis Vaccine Adsorbed)

Adakveo® (Crizanlizumab-Tmca)

Admelog® (Insulin Lispro Injection) 100 Units/mL

Advair (Diskus Or HFA) (Fluticasone/Salmeterol)

AeroChamber Plus Flow-Vu

Afinitor Disperz® (Everolimus Suspension)

Afinitor® (Everolimus)

Aimovig (Erenumab)

Alcensa (Alectinib)

Alimta® (Pemetrexed For Injection)

Alloderm

Alomide® (Lodoxamide Tromethamine Solution)

Alphagan P (Brimonidine Tartrate) Ophthalmic Solution

Amitiza (lubiprostone)

Anoro Ellipta (Umeclidinium/Vilanterol)

Apidra® (Insulin Glulisine Injection) 100 Units/mL

Aptiom® (eslicarbazepine acetate)

Aptivus (Tipranavir)

Aranesp (Darbepoetin Alfa)

Arixtra (Fondaparinux)

Armour Thyroid (Thyroid Tablets, USP) Tablets

Arnuity Ellipta (Fluticasone)

Aromasin® (Exemestane) Tablets

Arthrotec® (Diclofenac Sodium/Misoprostol) Tablets

Atrovent HFA (Ipratropium)

Avastin (Bevacizumab)

Avsola (Infliximab-Axxq)

Avycaz (Avibactam/Ceftazidime)

Balversa (Erdafitinib) Tablets     

Baqsimi® (Glucagon) Nasal Powder

Basaglar® (Insulin Glargine Injection)

Beconase AQ  (Beclomethasone Dipropionate Nasal Spray)

Belsomra® (Suvorexant) C-IV

Bendeka (Bendamustine)

Benefix® Coagulation Factor IX (Recombinant)

Benlysta  (Belimumab)

Beovu® (Brolucizumab-Dbll) Injection

BESPONSA (inotuzumab)

Betoptic S® (Betaxolol Hydrochloride Suspension)

Bevespi Aerosphere (Glycopyrrolate/Formoterol)

Blenrep (Belantamab)

Blincyto (Blinatumomab)

Boostrix (Tdap Vaccine)

BOSULIF (bosutinib)

Botox (Onabotulinumtoxina)

BRAFTOVI (encoarfenib)

Breo Ellipta (Fluticasone/Vilanterol)     

Breztri Aerosphere (Budesonide/Glycopyrrolate/Formoterol)

Brilinta (Ticagrelor)

Bydureon (Exenatide Extended Release)

Byetta (Exenatide)

Bystolic (Nebivolol) Tablets

Caduet (Amlodipine/Atorvastatin)

Calquence (Acalabrutinib)

CAMPTOSAR (irinotecan)

Canasa (Mesalamine) Suppository

Cancidas® (Caspofungin Acetate) For Injection

Carafate (Sucralfate) Oral Suspension

Carbatrol (carbamazepine extended-release) capsules

Cathflo Activase (Alteplase)

Caverject® (Alprostadil) Injection

Caverject® Impulse® (Alprostadil) Injection

Celebrex® (Celecoxib) Capsules

Celontin® (Methsuximide) Capsules, Usp

Chantix® (Varenicline) Tablets

Cialis® (Tadalafil) Tablets

Cibinqo™ (Abrocitinib) Tablets

Cimduo (Lamivudine/Tenofovir Disoproxil Fumarate) Tablet

Clozapine

Clozapine

Coartem® (Artemether And Lumefantrine)

Colcrys (colchicine) tablets

Combigan (Brimonidine Tartrate/Timolol Maleate) Ophthalmic Solution

Combivent Respimat (Ipratropium/Albuterol)

Corlanor (Ivabradine)

Cortifoam (Hydrocortisone 10%) Rectal Foam

Cosentyx® (Secukinumab)

Cotellic (Cobimetinib)

CREON (Pancrelipase) Delayed-Release Capsules

Crinone (Progesterone) Gel

Cyclosporine Capsules Modified

Cyclosporine Oral Solution Modified

Cymbalta® (Duloxetine Delayed-Release Capsules)

Cyramza® (Ramucirumab) Injection

Cystagon (Cysteamine) Capsules

Daliresp (Roflumilast)

Dalvance (Dalbavancin) Lyophilizate

Darzalex (Daratumumab) Injection For Iv Infusion

Darzalex Faspro (Daraumumab And Hyaluronidase-Fihj) Injection For Subcutaneous Use

DAURISMO (glasdegib)

Delstrigo™ (Doravirine, Lamivudine, And Tenofovir Disoproxil Fumarate) Tablets, For Oral Use

Delzicol (Mesalamine Dr) Capsules

Denavir (Penciclovir) Cream 1%

Depakote (Divalproex Sodium)

Depen (Penicillamine) Tablets

Depo®-Estradiol (Estradiol Cypionate) Injection, USP

Depo-Provera® (Medroxyprogesterone Acetate Injectable Suspension)

Detrol La (Tolterodine)

Detrol® (Tolterodine Tartrate) Tablets

Detrol® La (Tolterodine Tartrate) Extended-Release Capsules

Dexilant (dexlansoprazole) DR capsules

Dificid® (Fidaxomicin) For Oral Suspension 40 Mg/mL

Dificid® (Fidaxomicin) Tablets

Dilantin® (Extended Phenytoin Sodium) Capsules

Dipentum (Olsalazine) Capsule

Duavee™ (Conjugated Estrogens/Bazedoxifene) Tablets

Duopa (Carbidopa/Levodopa) Enteral Suspension

Durysta (Bimatoprost) Ocular Implant

Dymista (Azelastine/Fluticasone) Nasal Spray

Edurant (Rilpivirine) Tablets

Elestrin (Estradiol Gel) 0.06%

Eligard (leuprolide)

Eliquis® (Apixaban)

ELLENCE (epirubicin)

Elmiron (Pentosan Polysulfate Sodium) Capsules

EMCYT (estramustine)

Emend® (Aprepitant) 80 Mg, 125 Mg Capsules

Emend® (Aprepitant) For Oral Suspension 125 Mg

Emend® (Fosaprepitant Dimeglumine) For Injection 150 Mg

Emgality® (Galcanezumab-Gnlm) Injection

Empliciti® (Elotuzumab)

Emsam Transdermal System

Enbrel (Etanercept)

Engerix-B (Hepatitis B Vaccine)

Enspryng (Satralizumab-Mwge)

Entresto™ (Sacubitril/Valsartan)

Epipen & Epipen Jr (Epinephrine) Injection

Epivir-Hbv (Lamivudine Solution Or Tablets)

Epogen (Epoetin Alfa)

Erbitux® (Cetuximab) Injection

Erivedge (Vismodegib)

Erleada (Apalutamide) Tablets

Erygel (Erythromycin) Topical Gel 2%

Esbriet (Pirfenidone)

Estrace (Estradiol) Cream

Estring® (Estradiol Vaginal Ring)

Evenity (Romosozumab-Aqqg)

Evista® (Raloxifene Hydrochloride) Tablet

Evoclin (Clindamycin) Foam 1%

Evrysdi (Risdiplam)

Extavia® (Interferon Beta-1B)

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F-J

Falsodex (Fulvestrant)

Farxiga (Dapagliflozin)

Fasenra (Benralizumab)

Fasenra Pen (Benralizumab)

Felbatol (Felbamate)

Feldene® (Piroxicam) Capsules

Ferumoxytol Injection

Fetzima (Levomilnacipran) Extended Release Capsules And Titration Pack

Fiasp Flextouch (Insulin Aspart)

Flovent (Diskus Or HFA) (Fluticasone)

Forteo® (Teriparatide Injection)

Fosrenol (lanthanum carbonate)

Fragmin® (Dalteparin Sodium) Injection

Fulphila (Pegfilgastrim-Jmdb)

Fulvestrant Injection, For Intramuscular Use

FYARRO (sirolimus albumin-bound) for injection

Gabitril (Tigabine Hydrochloride) Tablets

Galzin (Zinc Acetate) Capsules

Gardasil®9 (Human Papillomavirus 9-Valent Vaccine, Recombinant) 

Gastrocrom (Cromolyn) Oral Concentrate

Gavreto (Pralsetinib)

Gazyva (Obinutuzumab)

Gelnique (Oxybutynin Chloride 10%) Gel

Gengraf Capsules (Cyclosporine, Usp [Modified])

Genotropin® (Somatropin) For Injection

Gilenya® (Fingolimod)

Giltorif (Afatinib)

Glatiramer Acetate

Glucagen Hypokit     

Glucagon™ (Glucagon For Injection)

Glyxambi (Empagliflozin/Metformin)

Granix (Tbo-Filgrastim) Injection

Haldol Decanoate (Haloperidol) Im Injection Only       

Hemlibra (Emcizumab-Kxwh)

Heparin Sodium Injection, Usp

Herceptin (Trastuzumab)

Herceptin Hylecta (Trastuzumab And Hyaluronidase-Oysk)

Herzuma (Trastuzumab-Pkrb) Injection

Humalog® Mix50/50™ (Insulin Lispro Protamine And Insulin Lispro Injectable Suspension)

Humalog® Mix75/25™ (Insulin Lispro Protamine And Insulin Lispro Injectable Suspension)

Humalog® U-100 (Insulin Lispro Injection)

Humalog® U-200 (Insulin Lispro Injection)

Humatrope® (Somatropin) For Injection

Humira (Adalimumab)

Humulin® 70/30 (Human Insulin Isophane Suspension And Human Insulin Injection)

Humulin® N (Isophane Insulin Human Suspension)

Humulin® R (Insulin Human Injection)

Humulin® R U-500 (Insulin Human Injection)

Hycamtin® (Topotecan Hydrochloride) For Injection

Hycamtin® (Topotecan) Capsules

IBRANCE (Palbociclib)

IDAMYCIN (idarubicin)

IDHIFA® (Enasidenib)

ILARIS® (Canakinumab)

ILEVRO® (Nepafenac Suspension)

Imbruvica (Ibrutinib) Capsules/Tablets

Imbruvica (Ibrutinib)

Imfinzi (Durvalumab)

Imitrex (Sumatriptan Nasal Spray)

Imlygic (Talimogene)

Imogam® Rabies-Ht Immune Globulin, [Human] Usp, Heat Treated

Imovax® Rabies Vaccine [Human Diploid Cell]

Impeklo (Clobetasol) Lotion

Incruse Ellipta (Umeclidinium)

Infed (Iron Dextran) Injection

Inflectra® (Infliximab-Dyyb) For Injection  

INLYTA (axitinib)

Inrebic® (Fedratinib)

Inspra (Eplerenone)

Intelence (Etravirine) Tablets

Intuniv (guanfacine) ER tablets

Invega Sustenna, Trinza And Hafyera (Paliperidone Palmitate) Extended-Release Injection

Invokamet (Canagliflozin/Metformin)

Invokamet Xr (Canagliflozin/Metformin Xr)

Invokana (Canagliflozin)

Iressa (Gefitinib)

Isentress® (Raltegravir) 400 Mg Film-Coated And 25 Mg And 100 Mg Chewable Tablets

Isentress® Hd (Raltegravir) 600 Mg Tablets

Isentress® Os (Raltegravir) 100 Mg Granules For Suspension

Istodax® (Romidepsin)

Jadenu ® (Deferasirox)

Jadenu® Sprinkle (Deferasirox) Granules

Janumet® (Sitagliptin And Metformin Hci) Tablets

Janumet® Xr (Sitagliptin And Metformin Hci Extended-Release) Tablets 

Januvia® (Sitagliptin) Tablets

Jardiance (Empagliflozin)

Jemperli (Dostarlimab)

Jentadueto & Jentadueto Xr (Linagliptin/Metformin)    

Jynarque (Tolvaptan) Tablets

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K-O

Kadcyla (Ado-Trastuzumab Emtansine)

Kaletra (Lopinavir/Ritonavir)

Kanjinti (Trastuzumab-Anns)

Kazano (alogliptin/metformin) tablets

Kesimpta® (Ofatumumab)

Keytruda® (Pembrolizumab) Injection [Liquid Formulation] 100 Mg

Kisqali® Femara® Co-Pack (Ribociclib And Letrozole) Tablets

Kisqali® (Ribociclib)

Kombiglyze Er (Saxagliptin/Metformin Er)

Koselugo (Selumetinib)

Kynmobi™ (apomorphine hydrochloride)

Kyprolis (Carilzomib)

Lamictal (Lamotrigine Chewable Or Orally Disintegrating Tablets)

Lamictal ODT (Lamotrigine Patient Titration Kits)

Lamictal Xr (Lamotrigine Er Or Patient Titration Kit)

Lantus® (Insulin Glargine Injection) 100 Units/mL

Latuda (lurasidone)

Leqvio® (Inclisiran)

Levemir (Insulin Detemir) Flextouch

Levoleucovorin Injection

Levoxyl® (Levothyroxine Sodium) Tablets

Lexapro (Escitalopram)

Lialda (mesalamine) DR tablets

Liletta (Levonorgestrel) Intrauterine Contraceptive

Lincocin® (Lincomycin) Injection, USP

Linzess (Linaclotide) Capsules

Lo Lestrin Fe

Lokelma (Sodium Zirconium Cyclosilicate)

LORBRENA (lorlatinib)

Lovenox® (Enoxaparin Sodium Injection)

Lucentis (Ranibizumab Injection)

Lumakras (Sotorasib)

Lumigan (Bimatoprost 0.01%) Ophthalmic Solution

Lumoxiti (Moxetumomab Pasudotox-Tdffk)

Lupron Depot (Leuprolide Acetate For Depot Suspension)

Lupron Depot-Ped (Leuprolide Acetate For Depot Suspension)

Lutathera® (Lutetium Lu 177 Dotatate)

Luxiq (Betamethasonevalerate) Foam

Lynparza (Olaparib)

Lyumjev™ (Insulin Lispro-Aabc) Injection

Malarone (Atovaquone And Proguanil)

Mavyret (Glecaprevir/Pibrentasvir)

Maxidex® (Dexamethasone Suspension)

Mayzent® (Siponimod)

Mekinist® (Trametinib)

MEKTOVI (bibimetinib)

Menest® (Esterified Estrogens) Tablets, Usp

Menquadfi® (Meningococcal [Groups A, C, Y, W] Conjugate Vaccine)

Mepron (Atovaquone Suspension)

Miacalcin Injection (calcitonin)

M-M-R® Ii (Measles, Mumps, And Rubella Virus Vaccine Live) 

Monovisc (High Molecular Weight Hyaluronan) Injection

Monurol (Fosfomycin Tromethamine) Oral Granules

Motegrity (prucalopride) tablets

Mozobil® (Plerixafor Injection)

Multaq® (Dronedarone) Tablets

Muse (Alprostadil) Urethral

Mvasi (Bevacizumab-Awwb)

Mycobutin® (Rifabutin) Capsules, Usp

Mydayis (amphetamine) ER capsules

MYLOTARG (gemtuzumab)

Namenda And Namenda Xr (Memantine)

Namzaric (Memantine Extended Release And Donepezil)

Natrelle

Nesina (alogliptin) tablets

Neulasta (Pegfilgrastim)

Neupogen (Filgrastim)

Nevanac® (Nepafenac Suspension)

Nicotrol® (Nicotine)

NIVESTYM (filgrastim-aafi)

Norpace® (Disopyramide Phosphate)

Norvir (Ritonavir) Tablets And Oral Solution

Novlog Mix 70/30 (Insulin Aspart Protamine And Insulin Aspart) Flexpen

Novolin 70/30 (Insulin Nph And Insulin R Mix) Vial

Novolin N Vial (Insulin Nph)

Novolin R Vial (Insulin Regular)

Novolog (Insulin Aspart) Flexpen

Noxafil® (Posaconazole) Delayed-Release Tablets 100 Mg

Noxafil® (Posaconazole) Oral Suspension, 40 Mg/Ml

Nplate (Romiplostim)

Nucala (Mepolizumab)

Nulojix® (Belatacept))

NUPLAZID (pimavanserin)

Nuvigil (Armodafinil) Tablets [C-IV]

NYVEPRIA (pegfilgrastim-apgf)

Ocrevus (Orelizumab)

Ofev (Nintedanib)

Ogivri* (Trastuzumab-Dkst)

Olumiant® (Baricitinib) Tablets

Olux (Clobetasol) Foam 0.05%

Olux-E (Clobetasol) Foam 0.05%

Omnitrope® Somatropin (Rdna Origin)

Onglyza (Saxagliptin)

Onureg® (Azactidine Tablets)

Opdivo® (Nivolumab)

Opdualag™ (Nivolumab And Relatlimab – Rmbw)

Opsumit (Macitentan) Tablets

Orencia® (Abatacept)

Oriahnn (Elagolix/Estradiol/Norethindrone)

Orilissa (Elgaolix) Tablets

Orthovisc (High Molecular Weight Hyaluronan) Injection

Oseni (alogliptin/pioglitazone) tablets

Otezla (Apremilast)

Ozempic (Semaglutide) Injection

Ozurdex (Dexamethasone) Ocular Implant

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P-T

Parsabiv (Etelcalcetide)

Pegasys (Peginterferon Alfa-2A)

Pentacel® Diptheria And Tetanus Toxoids And Acellular Pertussis Adsorbed, Inactivated Poliovirus And Haemophilus B Conjugate (Tetanus Toxoid Conjugate) Vaccine

Pentasa (mesalamine) ER capsules

Perforomist (Formoterol Fumarate) Inhalation Solution

Perjeta (Pertuzumab)

Phesgo (Pertuzumab, Trastuzumab, And Hyaluronidase-Zzxf)

Pifeltro™ (Doravirine) Tablets, For Oral Use

Piqray® (Alpelisib)

Pluvicto® (177Lu-Psma-617)

Pneumovax®23 (Pneumococcal Vaccine Polyvalent) 

Polivy (Polatuzumab Vedotin-Piiq)

Pomalyst® (Pomalidomide)

Ponvory (Ponesimod)

Portrazza® (Necitumumab) Injection

Pradaxa (Dabigatran)

Praluent (alirocumab)

Pred Forte (Prednisolone Acetate) Ophthalmic Suspension

Premarin® (Conjugated Estrogens) Tablets, Usp (Conjugated Estrogens Tablets

Premarin® (Conjugated Estrogens) Vaginal Cream (Conjugated Estrogens) Vaginal Cream

Premphase® (Conjugated Estrogens Plus Medroxyprogesterone Acetate) Tablets

Prempro® (Conjugated Estrogens/Medroxyprogesterone Acetate) Tablets

Pretomanid Tablet

Prevacid (lansoprazole) ODT tablets

Prevnar 13® Pneumococcal 13-Valent Conjugate Vaccine [Diphtheria Crm197 Protein]

Prevymis™ (Letermovir) 240 Mg Tablets

Prezcobix (Darunavir/Cobicistat)

Prezista (Darunavir)

Priftin® (Rifapentine) Tablets

Pristiq® (Desvenlafaxine) Extended-Release Tablets

Proair HFA (Albuterol Sulfate) Inhalation Aerosol

Proair Respiclick (Albuterol Sulfate) Inhalation Aerosol

Procrit (Epoetin Alfa)

Proctofoam Hc (Hydrocortisone Acetate 1% & Pramoxine 1%)

Proglycem (Diazoxide) Oral Suspension

Prolia (Denosumab)

Promacta® (Eltrombopag)

Prozac® (Fluoxetine Capsules)

Pulmicort Flexhaler (Budesonide)

Pulmozyme (Dornase Alfa) Inhalation Solution

Pylera (Bismuth Subcitrate Potassium, Metronidazole, And Tetracycline) Capsules

QNASL (Beclomethasone) Nasal Aerosol

QTERN (Dapagliflozin/Saxagliptin)

QULIPTA (Atogepant) Tablets

QVAR Redihaler (Beclomethasone Dipropionate HFA) Inhalation Aerosol

Rapaflo (Silodosin) Capsules

Rapamune® (Sirolimus)

Reblozyl® (Luspatercept-Aamt)

Recarbrio™ (Imipenem, Cilastatin, And Relebactam) For Injection, For Intravenous Use

Recombivax Hb® [Hepatitis B Vaccine (Recombinant)] 

Rectiv (Nitroglycerin) Ointment

Relenza (Zanamivir Inhalation Powder)

Relpax (Eletriptan)

Relpax® (Eletriptan Hydrobromide) Tablets

Remicade (Infliximab) Iv Infusion

Repatha (Evolocumab)

Restasis (Cyclosporine) Ophthalmic Emulsion

RETACRIT (epoetin alfa-epbx)

Retevmo™ (Selpercatinib) Capsules

Revatio (Sildenafil)

Revlimid® (Lenalidomide)

Rexulti (Brexpiprazole) Tablets

Reyvow® (Lasmiditan) Tablets C-V

Riabni (Rituximab-Arrx)

Rinvoq (Upadacitinib)

Risperdal Consta (Risperidone) Long-Acting Injection

Rituxan (Rituximab) For Granulomatosis With Polyangiitis (Gpa), Microscopic Polyangiitis (Mpa) Or Pemphigus Vulgaris (Pv)

Rituxan (Rituximab) For Oncology

Rituxan (Rituximab) For Rheumatoid Arthritis

Rituxan Hycela (Rituximab/Hyaluronidase Human)

Rowasa (Mesalamine) Rectal Suspension

Rozerem (ramelteon) tablets

Rozlytrek (Entrectinib)

RUXIENCE (rituximab-pvvr)

Rybelsus (Semalgutide) Tablets

Rybrevant (Amivantamab-Vmjw)

Rydapt® (Midostaurin)

Samsca (Tolvaptan)

Sandostatin Lar® Depot (Octreotide Acetate)

Saphnelo (Anifrolumab-Fnia)

Saphris (Asenapine Maleate) Sublingual Tablet

Savella (Milnacipran) Tablets

Scemblix® (Asciminib) Tablets

Semglee (Insulin Glargine)

Sensipar (Cinacalcet)

Serevent (Diskus) (Salmeterol)

Sf Rowasa (Mesalamine) Rectal Suspension

Shingrix  (Zoster Vaccine)

Simponi (Golimumab) Injection

Sirturo (Bedaquiline) Tablets

Skelaxin® (Metaxalone) Tablets

Skyrizi (Risankizumab-Rzaa)

Soliqua® 100/33 (Insulin Glargine & Lixisenatide) Injection 100 Units/Ml And 33 Mcg/mL

Somavert® (Pegvisomant) For Injection

Spiriva Handihaler Or Respimat (Tiotropium)

Sporanox (Itraconazole) Capsules And Oral Solution

Spravato (Esketamine) Nasal Spray [CIII]

Sprycel® (Dasatinib)

Stelara (Ustekinumab) For Subcutaneous Or Iv Use

Stiolto Respimat (Tiotropium/Olodaterol)

Strattera® (Atomoxetine) Capsules

Strattice (Reconstructive Tissue Matrix)

Striverdi Respimat (Olodaterol)

Stromectol® (Ivermectin) Tablets

Susvimo (Ranibizumab)

SUTENT (sunitinib)

Symbicort (Budesonide/Formoterol)

Symbyax® (Olanzapine And Fluoxetine) Capsules

Symlin (Pramlintide)

Symtuza (Darunavir, Cobicistat, Emtricitabine, Tenofovir Alafenamide) Tablets

Synarel® (Nafarelin Acetate) Nasal Solution

Synjardy & Synjardy Xr (Empagliflozin/Metformin)

Synribo (Omacetaxine) For Injection

Synthroid (Levothyroxine Sodium) Tablets

Tabrecta™ (Capmatinib)

Tafinlar® (Dabrafenib)

Tagrisso (Osimertinib)

Taltz® (Ixekizumab) Injection

TALZENNA (talazoparib)

Tasigna® (Nilotinib)

Tecentriq (Atezolizumab)

Teflaro (Ceftaroline Fosamil) Powder For Injection

Tenivac® (Tetanus And Diphtheria Toxoids Adsorbed

Thalomid® (Thalidomide)

Thymoglobulin® [Anti-Thymocyte Globulin (Rabbit)

Tikosyn® (Dofetilide) Capsules

TNKase (Tenecteplase)

Tobi (Tobramycin) Ampules Or Podhalers

Tobradex® (Ophthalmic Ointment)

TORISEL (temsirolimus)

Toujeo® (insulin glargine injection) 300 Units/mL (1.5 mL or 3.0 mL pens)

Toviaz® (Fesoterodine Fumarate) Extended-Release Tablets

Tracleer (Bosentan)

Tradjenta (Linagliptin)

TRAZIMERA (trastuzumab-qyyp)

Treanda (Bedamustine) For Injection

Trecator® (Ethionamide) Tablets

Tremfya (Guselkumab) For Subcutaneous Use

Tresiba (Insulin Degludec) Flextouch

Triesence® (Triamcinolone Acetonide Injectable Suspension)

Trijardy Xr (Empagliflozin/Linagliptin/Metformin)

Trintellix (vortioxetine tablets)

Trisenox (Arsenice Trioxide) Injection

Trulicity® (Dulaglutide) Injection

Trumenba® (Meningococcal Group B Vaccine)

Trusopt® (Dorzolamide Hydrochloride Ophthalmic Solution) 2% 

Truxima (Rituximab-Abbs) Injection

Tygacil® (Tigecycline) For Injection

Tykerb® (Lapatinib)

TYMLOS (abaloparatide) injection

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U-Z

Ubrelvy (Ubrogepant) Tablets

Uptravi (Selexipag)

Vabysmo (Faricimab-Svoa)

Vaqta® (Hepatitis A Vaccine, Inactivated) 

Varivax® (Varicella Virus Vaccine Live) 

Vaxneuvance™ (Pneumococcal 15-Valent Conjugate Vaccine) 

Vectibix (Panitumumab)

Veletri (Epoprostenol)

Venclexta (Venetoclax Tablets)

Venclexta (Venetoclax) Tablets

Ventavis (Iloprostol)

Verquvo™ (Vericiguat) 2.5 Mg, 5 Mg, 10 Mg Tablets

Verzenio® (Abemaciclib) Tablets

Veltassa (patiromer)

Vfend® (Voriconazole)

Viberzi (Eluxadoline)

Victoza (Liraglutide) Pen

Vidaza® (Azacitidine For Injection)

Viibryd (Vilazodone)

Vijoice® (Alpelisib)

Viokace (Pancrelipase) Tablets

Viramune Xr (Nevirapine)

VIZIMPRO (dacaomitinib)

Votrient® (Pazopanib)

Vraylar (Cariprazine) Capsules

Vyndaqel® (Tafamidis Meglumine) Capsules

Vyvanse (lisdexamfetamine) capsules and tablets

Welireg™ (Belzutifan) 40 Mg Tablets

Wixela (Fluticasone/Salmeterol)

XALKORI (crizotinib)      

Xanax® CIV (Alprazolam) Tablets

Xarelto (Rivaroxaban) Tablets Or Oral Solution

Xeljanz® (Tofacitinib) Oral Solution

Xeljanz® (Tofacitinib) Tablets

Xeljanz® Xr (Tofacitinib) Extended-Release Tablets

Xeloda (Capecitabine)

Xen (Gel Stent)

Xgeva (Denosumab)

Xigduo Xr (Dapagliflozin/Metformin Er)

Xiidra® (Lifitegrast Ophthalmic Solution)

Xolair (Omalizumab)

Xulane (Norelgestromin And Ethinyl Estradiol Transdermal System)

Xultophy (Insulin Degludec & Liraglutide) Pen

Xyntha® Antihemophilic Factor (Recombinant)

Yervoy® (Ipilimumab)

Yondelis (Trabectedin) For Iv Infusion

Yupelri (Revefenacin)

Zarontin® (Ethosuximide)

Zarxio™ (Filgrastim-Sndz)

Zelboraf (Vemurafenib)

Zenpep (Pancrelipase) Delayed Release Capsule

Zepatier® (Elbasvir And Grazoprevir) 

Zeposia® (Ozanimod)

Zerbaxa™ (Ceftolozane And Tazobactam) For Injection For Intravenous Use 

Ziextenzo® (Pegfilgrastim-Bmez)‎

Zinplava™ (Bezlotoxumab) Injection 25 Mg/mL

ZIRABEV (bevacizumab-bvzr)

Zolinza® (Vorinostat) 100 Mg Capsules

Zykadia® (Ceritinib)

Zynlonta (loncastuximab tesirine)

Zyprexa® (Olanzapine) Tablet

Zyprexa® Zydis® (Olanzapine) Tablet

Zytiga (Abiraterone) Tablets

Zyvox® (Linezolid)

Manufacturer

Income documentation required

Medication delivery

FPL cutoff (%) or income threshold for single person($)

FPL cutoff 2

FPL cutoff 3

AADI

No

Office

400

 

 

AbbVie

No

Home

$81,150

 

 

Acadia

Application through office staff

Home

Any for uninsured

 

 

ADC

No

Home

550

 

 

Amgen

No

Home

500

 

 

AstraZeneca

No

Home

300

500

 

Boehringer Ingelheim

No

Home

250

 

 

Bristol Myers Squibb

No-but encouraged

Home

300

 

 

GlaxoSmithKline (GSK)

No

Home

250

 

 

Johnson & Johnson

No

Home

300

400

600

Lilly

No

Home

300

400

500

Merck

No

Home

400

 

 

MyPraluent

No-but encouraged

Home

300

 

 

Mylan (Viatris)

Yes

Home

400

500

 

Nestle Health

Yes

Home

400

 

 

Novartis

No

Home

$70,000

 

 

Novo Nordisk

No

Office

400

 

 

Otsuka

Yes

Home

300

700

 

Pfizer

Yes

Office

$49,960

400

 

Pfizer Oncology

No

Home

500

 

 

Radius

No-SSN acceptable

Home

300

 

 

Roche (Genentech)

No

Home

$75,000

 

 

Sanofi

No

Office

400

 

 

Sunovion

Yes

Home

300

 

 

TAKEDA

Yes

Home

500

 

 

TEVA

No

Home

300

500

 

Tolmar

Yes

Home

500

 

 

Veltassa

Yes

Home

500

 

 

FPL=federal poverty limit

SSN=social security number

Programs that do NOT provide automatic refills: AbbVie, Boehringer Ingelheim, GSK, Novartis, Pfizer

Programs that needle request need indicated: Novo Nordisk (Lilly does NOT include needles)

Programs that require separate prescription be sent: GSK

Programs that require applications mailed in: Merck

Programs that send pharmacy card with ID, BIN, and Rx Group instead of medication itself: Johnson&Johnson for Xarelto

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Income thresholds based on federal poverty limit (FPL)A 2022

Household size

100% ($)

133%

($)

150%

($)

200%

($)

250%

($)

300%

($)

400%

($)

500%

($)

1

13,590

18,075

20,385

27,180

33,975

40,770

54,360

67,950

2

18,310

24,352

27,465

36,620

45,775

54,930

73,240

91,550

3

23,030

30,630

34,545

46,060

57,575

69,090

92,120

115,150

4

27,750

36,908

41,625

55,500

69,375

83,250

111,000

138,750

5

32,470

43,185

48,705

64,940

81,175

97,410

129,880

162,350

6

37,190

49,463

55,785

74,380

92,975

111,570

148,760

185,950

7

41,910

55,740

62,865

83,820

104,775

125,730

167,640

209,550

8

46,630

62,018

69,945

93,260

116,575

139,890

186,520

233,150

Each additional

4,720

6,278

7,080

9,440

11,800

14,160

18,880

23,600

A: Federal poverty limits are subject to change on an annual basis

 

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Medications with PAP per drug manufacturer

AADIAssist Patient Assistance Program

Eligibility

US resident

 

<400% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<400% FPL)

1

54,360

2

73,240

3

92,120

4

111,000

5

129,880

>5

Add 4,720 for each additional person

 

Medications eligible for assistance

FYARRO (sirolimus albumin bound) for injection

 

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AbbVie Assist (usually reviewed within 2 business days)

Eligibility

US resident

 

Below income threshold

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

 

1

81,540

2

109,860

3

138,180

4

166,500

>5

Add 28,320 for each additional person

Proof of income

Most recent federal tax form, W2, or social security statements

 

Medications eligible for assistance

Acuvail (ketorolac tromethamine) ophthalmic solution

AeroChamber Plus Flow-Vu

Alloderm

Alphagan P (brimonidine tartrate) ophthalmic solution

Armour Thyroid (thyroid tablets, USP) tablets

Avycaz (avibactam/ceftazidime)

BOTOX (onabotulinumtoxinA)

Bystolic (nebivolol) tablets

Canasa (mesalamine) suppository

Carafate (sucralfate) oral suspension

Combigan (brimonidine tartrate/timolol maleate) ophthalmic solution

CREON (Pancrelipase) delayed-release capsules

Crinone (progesterone) gel

Dalvance (dalbavancin) lyophilizate

Delzicol (mesalamine DR) capsules

Depakote (divalproex sodium)

Duopa (carbidopa/levodopa) enteral suspension

Durysta (Bimatoprost) ocular implant

Estrace (estradiol) cream

Fetzima (Levomilnacipran) extended release capsules and titration pack

Gelnique (oxybutynin chloride 10%) gel

GENGRAF capsules (cyclosporine, USP [MODIFIED])

HUMIRA (adalimumab)

IMBRUVICA (ibrutinib)

Infed (iron dextran) injection

KALETRA (lopinavir/ritonavir)

Lexapro (escitalopram)

Liletta (levonorgestrel) intrauterine contraceptive

Linzess (linaclotide) capsules

Lo Lestrin fe

Lumigan (Bimatoprost 0.01%) ophthalmic solution

Lupron Depot-Ped (leuprolide acetate for depot suspension)

Lupron Depot (leuprolide acetate for depot suspension)

MAVYRET (Glecaprevir/Pibrentasvir)

Monurol (Fosfomycin tromethamine) oral granules

Namenda and Namenda XR (memantine)

Namzaric (memantine extended release and donepezil)

NATRELLE

NORVIR (ritonavir) tablets and oral solution

Oriahnn (Elagolix/estradiol/norethindrone)

ORILISSA (Elgaolix) tablets

Ozurdex (dexamethasone) ocular implant

Pred Forte (prednisolone acetate) ophthalmic suspension

Pylera (bismuth Subcitrate potassium, metronidazole, and tetracycline) capsules

Qulipta (Atogepant) tablets

Rapaflo (silodosin) capsules

Rectiv (nitroglycerin) ointment

Restasis (cyclosporine) ophthalmic emulsion

RINVOQ (upadacitinib)

Saphris (asenapine maleate) sublingual tablet

Savella (milnacipran) tablets

SKYRIZI (Risankizumab-rzaa)

STRATTICE (reconstructive tissue matrix)

Synthroid (levothyroxine sodium) tablets

Teflaro (ceftaroline fosamil) powder for injection

Ubrelvy (ubrogepant) tablets

Venclexta (venetoclax) tablets

Viberzi (eluxadoline)

Viibryd (vilazodone)

Vraylar (cariprazine) capsules

Xen (gel stent)

Contact info-Phone: 1-800-222-6885 Fax: 1-866-898-1473

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Acadia Connect

Eligibility

US resident

 

Any income

 

Uninsured/Medicare

 

Medications eligible for assistance

NUPLAZID (pimavanserin)

 

 

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ADC Patient Support

Eligibility

US resident

 

<550% FPL

 

Uninsured/Medicare

 

Medications eligible for assistance

Zynlonta (loncastuximab tesirine)

 

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AMGEN safety net program

Eligibility

US resident

>6 months

 

<500% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<500% FPL)

1

67,950

2

91,550

3

115,150

4

138,750

>5

Click for FPL for household larger than 5 or add 23,600 per each additional person

 

Medications eligible for assistance

Aimovig (erenumab)

ARANESP (darbepoetin alfa)

AVSOLA (infliximab-axxq)

BLINCYTO (blinatumomab)

Corlanor (ivabradine)

Enbrel (etanercept)

Epogen (epoetin alfa)

EVENITY (romosozumab-aqqg)

IMLYGIC (talimogene)

KANJINTI (trastuzumab-anns)

Kyprolis (carilzomib)

LUMAKRAS (sotorasib)

MVASI (bevacizumab-awwb)

Neulasta (pegfilgrastim)

NEUPOGEN (filgrastim)

Nplate (romiplostim)

Otezla (apremilast)

Parsabiv (etelcalcetide)

Prolia (denosumab)

Repatha (evolocumab)

RIABNI (rituximab-arrx)

Sensipar (cinacalcet)

Vectibix (panitumumab)

XGEVA (denosumab)

Contact info varies by program, see individual medication application for phone and fax

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AstraZeneca AZ&ME program

Eligibility

US resident

 

< 300-500% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

Group 1 (< 300% FPL)

Group 2 (<500% FPL)

1

40,770

67,950

2

54,930

91,550

3

69,090

115,150

4

83,250

138,750

>5

Call AZ&ME 1-800-292-6363

 

Medication eligible for assistance

Insurance Group

Medication name

1

BEVESPI AEROSPHERE (glycopyrrolate/formoterol)

1

BREZTRI AEROSPHERE (budesonide/glycopyrrolate/formoterol)

1

BRILINTA (ticagrelor)

1

BYDUREON (exenatide extended release)

1

BYETTA (exenatide)

2

CALQUENCE (acalabrutinib)

1

DALIRESP (roflumilast)

1

FARXIGA (dapagliflozin)

2

FASENRA (benralizumab)

2

FASENRA pen (benralizumab)

2

FALSODEX (fulvestrant)

2

IMFINZI (durvalumab)

2

IRESSA (gefitinib)

1

KOMBIGLYZE ER (saxagliptin/metformin ER)

2

KOSELUGO (selumetinib)

1

LOKELMA (sodium zirconium cyclosilicate)

2

LUMOXITI (moxetumomab pasudotox-tdffk)

2

LYNPARZA (Olaparib)

1

ONGLYZA (saxagliptin)

1

PULMICORT FLEXHALER (budesonide)

1

QTERN (dapagliflozin/saxagliptin)

2

SAPHNELO (anifrolumab-fnia)

1

SYMBICORT (budesonide/formoterol)

1

SYMLIN (pramlintide)

2

TAGRISSO (Osimertinib)

1

XIGDUO XR (dapagliflozin/metformin ER)

Contact info-Phone: 1-800-292-6363 Fax for non-specialty medications: 1-800-961-8323

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Boehringer Ingelheim (BI Cares Program)

Eligibility

US resident

 

<250% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<250% FPL)

1

33,975

2

45,775

3

57,575

4

69,375

5

81,175

Click for FPL for household larger than 5

 

Medications eligible for assistance

Aptivus (tipranavir)

Atrovent HFA (ipratropium)

COMBIVENT Respimat (ipratropium/albuterol)

GILTORIF (afatinib)$

Glyxambi (empaglizoin/metformin)

Jardiance (empagliflozin)

Jentadueto & Jentadueto XR (linagliptin/metformin)

OFEV (nintedanib)$

Pradaxa (dabigatran)

Spiriva Handihaler or Respimat (tiotropium)

Stiolto Respimat (tiotropium/olodaterol)

Striverdi Respimat (olodaterol)

Synjardy & Synjardy XR (empagliflozin/metformin)

Tradjenta (linagliptin)

Trijardy XR (empagliflozin/linagliptin/metformin)

Viramune XR (nevirapine)

$ Has individual application

Contact info: Phone: 1-800-556-8317  Fax: 1-866-851-2827

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Bristol Myers Squibb

Eligibility

US resident

 

< 300% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<300% FPL)

1

40,770

2

54,930

3

69,090

4

83,250

5

97,410

Each additional person

14,160

           

Medications eligible for assistance

ABRAXANE® (paclitaxel protein-bound particles for injectable suspension (albumin-bound))

ELIQUIS® (apixaban)

EMPLICITI® (elotuzumab)

IDHIFA® (Enasidenib)

INREBIC® (fedratinib)

ISTODAX® (Romidepsin)

NULOJIX® (belatacept))

ONUREG® (azactidine tablets)

OPDIVO® (nivolumab)

OPDUALAG™ (nivolumab and relatlimab – rmbw)

ORENCIA® (Abatacept)

POMALYST® (pomalidomide)

REBLOZYL® (luspatercept-aamt)

REVLIMID® (lenalidomide)

SPRYCEL® (dasatinib)

THALOMID® (thalidomide)

VIDAZA® (azacitidine for injection)

YERVOY® (Ipilimumab)

ZEPOSIA® (ozanimod)

Application for Eliquis, Nulojix, and Orencia are the same

Contact info-Phone: 1-800-736-0003 Fax: 1-800-736-1611 Fax 2: 833-967-1666

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GlaxoSmithKline – GSK for You

Eligibility

US resident

 

< 250% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<250% FPL)

1

33,975

2

45,774.96

3

57,575.04

4

69,375

>5

Add 11,859.96

 

Medications eligible for assistance

ADVAIR (diskus or HFA) (Fluticasone/salmeterol)

ANORO ELLIPTA (Umeclidinium/vilanterol)

ARNUITY ELLIPTA (Fluticasone)

BECONASE AQ  (Beclomethasone dipropionate nasal spray)

BENLYSTA  (Belimumab)

BLENREP (Belantamab)

BOOSTRIX (Tdap vaccine)

BREO ELLIPTA (Fluticasone/vilanterol)

EPIVIR-HBV (Lamivudine solution or tablets)

ENGERIX-B (Hepatitis B vaccine)

FLOVENT (diskus or HFA) (Fluticasone)

IMITREX (Sumatriptan nasal spray)

INCRUSE ELLIPTA (Umeclidinium)

JEMPERLI (Dostarlimab)

LAMICTAL (Lamotrigine chewable or orally disintegrating tablets)

LAMICTAL ODT (Lamotrigine patient titration kits)

LAMICTAL XR (Lamotrigine ER or patient titration kit)

MALARONE (Atovaquone and proguanil )

MEPRON (Atovaquone suspension)

NUCALA (Mepolizumab)

RELENZA (Zanamivir inhalation powder)

SEREVENT (diskus) (Salmeterol)

SHINGRIX  (Zoster vaccine)

Contact info: Phone:1-866-728-4368 Fax: 1-855-474-3063

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Johnson & Johnson

Eligibility

US resident

 

< 300-600% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

Group 1 (< 300% FPL)

Group 2 (<400% FPL)

Group 3 (<600% FPL)

1

40,770

54,360

81,540

2

54,930

73,240

109,860

3

69,090

92,120

138,180

4

83,250

111,000

166,500

>5

Call Johnson & Johnson 1-800-652-6227

 

Medications eligible for assistance

Insurance group

Medication name

3

BALVERSA (erdafitinib) tablets

3

DARZALEX (daratumumab) injection for IV infusion

3

DARZALEX FASPRO (daraumumab and hyaluronidase-fihj) injection for subcutaneous use

1

EDURANT (rilpivirine) tablets

1

ELMIRON (pentosan polysulfate sodium) capsules

3

ERLEADA (paludomid) tablets

1

HALDOL Decanoate (haloperidol) IM injection only

3

IMBRUVICA (ibrutinib) capsules/tablets

1

INTELENCE (etravirine) tablets

1

INVEGA SUSTENNA, TRINZA and HAFYERA (paliperidone palmitate) extended-release injection

1

INVOKAMET (canagliflozin/metformin)

1

INVOKAMET XR (canagliflozin/metformin XR)

1

INVOKANA (canagliflozin)

2

MONOVISC (high molecular weight hyaluronan) injection

2

OPSUMIT (macitentan) tablets

2

ORTHOVISC (high molecular weight hyaluronan) injection

2

PONVORY (ponesimod)

1

PREZCOBIX (darunavir/cobicistat)

1

PREZISTA (darunavir)

2

PROCRIT (epoetin alfa)

3

REMICADE (infliximab) IV infusion

1

RISPERDAL CONSTA (risperidone) long-acting injection

3

RYBREVANT (amivantamab-vmjw)

3

SIMPONI (golimumab) injection

1

SIRTURO (bedaquiline) tablets

1

SPORANOX (itraconazole) capsules and oral solution

1

SPRAVATO (esketamine) nasal spray [CIII]

3

STELARA (ustekinumab) for subcutaneous or IV use

1

SYMTUZA (darunavir, cobicistat, emtricitabine, tenofovir alafenamide) tablets

3

TRACLEER (bosentan)

3

TREMFYA (guselkumab) for subcutaneous use

3

UPTRAVI (selexipag)

3

VELETRI (epoprostenol)

3

VENTAVIS (iloprostol)

1

XARELTO (rivaroxaban) tablets or oral solution

3

YONDELIS (trabectedin) for IV infusion

3

ZYTIGA (abiraterone) tablets

Contact info-Phone: 1-800-652-6227 Fax: 1-888-526-5168

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Lilly Cares Program

Eligibility

US resident

 

< 300-500% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

Group 1 (< 300% FPL)

Group 2 (<400% FPL)

Group 3 (<500% FPL)

1

40,770

54,360

67,950

2

54,930

73,240

91,550

3

69,090

92,120

115,150

4

83,250

111,000

138,750

>5

Call Lilly cares 1-800-545-6962

 

Medications eligible for assistance

Insurance Group

Medication name

Package insert

Patient education

3

Alimta® (pemetrexed for injection)

Prescribing Information

Patient Information

2

Baqsimi® (glucagon) nasal powder

Prescribing Information

Patient Information

2

Basaglar® (insulin glargine injection)

Prescribing Information

Patient Information

2

Cialis® (tadalafil) tablets

Prescribing Information

Patient Information

1

Cymbalta® (duloxetine delayed-release capsules)

Prescribing Information

Medication Guide

3

Cyramza® (ramucirumab) injection

Prescribing Information

2

Emgality® (galcanezumab-gnlm) injection

Prescribing Information

Patient Information

3

Erbitux® (cetuximab) injection

Prescribing Information

1

Evista® (raloxifene hydrochloride) Tablet

Prescribing Information

Medication Guide

1

Forteo® (teriparatide injection)

Prescribing Information

Medication Guide

2

Glucagon (glucagon for injection)

Prescribing Information

Patient Information

2

Humalog® U-100 (insulin lispro injection)

Prescribing Information

Patient Information

2

Humalog® U-200 (insulin lispro injection)

Prescribing Information

Patient Information

2

Humalog® Mix50/50 (insulin lispro protamine and insulin lispro injectable suspension)

Prescribing Information

Patient Information

2

Humalog® Mix75/25 (insulin lispro protamine and insulin lispro injectable suspension)

Prescribing Information

Patient Information

3

Humatrope® (somatropin) for injection

Prescribing Information

Patient Information: Cartridge
Patient Information: Vial

2

Humulin® 70/30 (human insulin isophane suspension and human insulin injection)

Prescribing Information

Patient Information

2

Humulin® N (isophane insulin human suspension)

Prescribing Information

Patient Information

2

Humulin® R (insulin human injection)

Prescribing Information

Patient Information

2

Humulin® R U-500 (insulin human injection)

Prescribing Information

Patient Information

2

Lyumjev (insulin lispro-aabc) injection

Prescribing Information

Patient Information

3

Olumiant® (baricitinib) tablets

Prescribing Information

Medication Guide

3

Portrazza® (necitumumab) injection

Prescribing Information

1

Prozac® (fluoxetine capsules)

Prescribing Information

Medication Guide

3

Retevmo (selpercatinib) capsules

Prescribing Information

Patient Information

2

Reyvow® (lasmiditan) tablets C-V

Prescribing Information

Medication Guide

1

Strattera® (atomoxetine) capsules

Prescribing Information

Medication Guide

1

Symbyax® (olanzapine and fluoxetine) capsules

Prescribing Information

Medication Guide

3

Taltz® (ixekizumab) injection

Prescribing Information

Medication Guide

2

Trulicity® (dulaglutide) injection

Prescribing Information

Medication Guide

3

Verzenio® (abemaciclib) tablets

Prescribing Information

Patient Information

1

Zyprexa® (olanzapine) Tablet

Prescribing Information

Medication Guide

1

Zyprexa® Zydis® (olanzapine) Tablet

Prescribing Information

Medication Guide

Contact info-Phone: 1-800-545-6962 Fax: 1-844-431-6650

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Merck and Co – Merck Helps: patient assistance program

Eligibility

US resident

 

< 400% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<400% FPL)

1

54,360

2

73,240

3

92,120

4

111,000

5

129,880

>5

Add 4,720 for each additional person

1.      

Medications eligible for assistance

BELSOMRA® (suvorexant) C-IV 

CANCIDAS® (caspofungin acetate) for Injection

DELSTRIGO™ (doravirine, lamivudine, and tenofovir disoproxil fumarate) tablets, for oral use

DIFICID® (fidaxomicin) tablets

DIFICID® (fidaxomicin) for oral suspension 40 mg/mL

EMEND® (aprepitant) for Oral Suspension 125 mg

EMEND® (aprepitant) 80 mg, 125 mg capsules

EMEND® (fosaprepitant dimeglumine) for Injection 150 mg

GARDASIL®9 (Human Papillomavirus 9-valent Vaccine, Recombinant) 

ISENTRESS® (raltegravir) 400 mg film-coated and 25 mg and 100 mg chewable Tablets

ISENTRESS® HD (raltegravir) 600 mg Tablets

ISENTRESS® OS (raltegravir) 100 mg Granules for Suspension

JANUMET® (sitagliptin and metformin HCI) Tablets

JANUMET® XR (sitagliptin and metformin HCI extended-release) Tablets 

JANUVIA® (sitagliptin) Tablets

KEYTRUDA® (pembrolizumab) Injection [liquid formulation] 100 mg

M-M-R® II (Measles, Mumps, and Rubella Virus Vaccine Live) 

NOXAFIL® (posaconazole) oral suspension, 40 mg/mL

NOXAFIL® (posaconazole) delayed-release tablets 100 mg

PIFELTRO™ (doravirine) tablets, for oral use

PNEUMOVAX®23 (Pneumococcal Vaccine Polyvalent) 

PREVYMIS™ (letermovir) 240 mg Tablets

RECARBRIO™ (imipenem, cilastatin, and relebactam) for injection, for intravenous use

RECOMBIVAX HB® [Hepatitis B Vaccine (Recombinant)] 

STROMECTOL® (ivermectin) Tablets

TRUSOPT® (dorzolamide hydrochloride ophthalmic solution) 2% 

VAQTA® (Hepatitis A Vaccine, Inactivated) 

VARIVAX® (Varicella Virus Vaccine Live) 

VAXNEUVANCE™ (Pneumococcal 15-valent conjugate vaccine) 

VERQUVO™ (vericiguat) 2.5 mg, 5 mg, 10 mg tablets

WELIREG™ (belzutifan) 40 mg Tablets

ZEPATIER® (elbasvir and grazoprevir) 

ZERBAXA™ (ceftolozane and tazobactam) for Injection for Intravenous Use 

ZINPLAVA™ (bezlotoxumab) Injection 25 mg/ml

ZOLINZA® (vorinostat) 100 mg Capsules

Contact info-Phone: 1-800-727-5400

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MyPraluent Patient Assistance Program

Eligibility

US resident

 

>135% < 300% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<300% FPL)

1

40,770

2

54,930

3

69,090

4

83,250

>5

Contact Radius program at 1-844-772-5836

 

Medication eligible for assistance

Praluent (alirocumab)

Contact info-Phone:1-844-772-5836 Fax: 1-844-855-7278

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Mylan pharmaceuticals now Viatris

Eligibility

US resident

 

< 400-500% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

Group 1 & 2 medications

<400% FPL

Fulphila & Ogivri

(<500% FPL)

1

54,360

67,950

2

73,240

91,550

3

92,120

115,150

4

111,000

138,750

5

129,880

162,350

>5

Add 23,600 for each additional person in household

 

Medications eligible for assistance

Insurance Group

Medication name

1

Arixtra (fondaparinux)

2

Caduet (amlodipine/atorvastatin)

1

Cimduo (lamivudine/tenofovir disoproxil fumarate) tablet

1

Clozapine

1

Cortifoam (hydrocortisone 10%) rectal foam

1

Cystagon (cysteamine) capsules

1

Denavir (penciclovir) cream 1%

1

Depen (penicillamine) tablets

2

Detrol LA (tolterodine)

1

Dipentum (olsalazine) capsule

1

Dymista (azelastine/fluticasone) nasal spray

1

Elestrin (estradiol gel) 0.06%

1

Emsam transdermal system

2

EpiPen & EpiPen Jr (epinephrine) injection

1

Erygel (erythromycin) topical gel 2%

1

Evoclin (clindamycin) foam 1%

1

Felbatol (felbamate)

2

Fulphila (pegfilgastrim-jmdb)*

1

Gastrocrom (cromolyn) oral concentrate

2

Glatiramer Acetate

1

Impeklo (clobetasol) lotion

2

Inspra (eplerenone)

1

Luxiq (betamethasonevalerate) foam

1

Miacalcin injection (calcitonin)

1

Muse (alprostadil) urethral

2

Ogivri* (trastuzumab-dkst)

1

Olux (clobetasol) foam 0.05%

1

Olux-E (clobetasol) foam 0.05%

1

Perforomist (formoterol fumarate) inhalation solution

1

Pretomanid tablet

1

Proctofoam HC (hydrocortisone acetate 1% & pramoxine 1%)

2

Relpax (eletriptan)

1

Rowasa (mesalamine) rectal suspension

1

Semglee (insulin glargine)

1

SF Rowasa (mesalamine) rectal suspension

2

Tobi (tobramycin) ampules or podhalers

1

Wixela (fluticasone/salmeterol)

1

Xulane (norelgestromin and ethinyl estradiol transdermal system)

1

Yupelri (revefenacin)

*FPL threshold 500%

Contact info-Phone: 888-417-5780  Fax: 877-427-7290

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Nestle Health Science Patient assistance program

Eligibility

US resident

 

< 400% FPL

 

Uninsured

 

Household size

Annual household income ($) threshold

(<400% FPL)

1

54,360

2

73,240

3

92,120

4

111,000

5

129,880

>5

Add 4,720 for each additional person

 

Medication eligible for assistance

Viokace (pancrelipase) tablets

Zenpep (pancrelipase) delayed release capsule

Contact info-Phone: 1-855-210-6228 Fax: 1-877-867-1831

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Novartis Patient Assistance Foundation

Eligibility

US resident

 

Below annual income threshold

 

Uninsured

 

Household size

Annual household income ($) threshold

1

70,000

2

100,000

3

125,000

4

150,000

>5

Add 25,000 per additional person

 

Medications eligible for assistance

Adakveo® (crizanlizumab-tmca)

Afinitor® (everolimus)

Afinitor Disperz® (everolimus suspension)

Alomide® (lodoxamide tromethamine solution)

Beovu® (brolucizumab-dbll) Injection

Betoptic S® (betaxolol hydrochloride suspension)

Coartem® (artemether and lumefantrine)

Cosentyx® (secukinumab)

Entresto™ (sacubitril/valsartan)

Extavia® (interferon beta-1b)

Ferumoxytol injection

Fulvestrant injection, for intramuscular use

Gilenya® (fingolimod)

Hycamtin® (topotecan) Capsules

Hycamtin® (topotecan hydrochloride) For Injection

Ilaris® (canakinumab)

Ilevro® (nepafenac suspension)

Jadenu ® (deferasirox)

Jadenu® Sprinkle (deferasirox) granules

Kesimpta® (ofatumumab)

Kisqali® (ribociclib)

Kisqali® Femara® Co-Pack (ribociclib and letrozole) tablets

Leqvio® (Inclisiran)

Lutathera® (lutetium Lu 177 dotatate)

Levoleucovorin Injection

Maxidex® (dexamethasone suspension)

Mayzent® (Siponimod)

Mekinist® (trametinib)

Nevanac® (nepafenac suspension)

Omnitrope® Somatropin (rDNA origin)

Piqray® (alpelisib)

Pluvicto® (177Lu-PSMA-617)

Promacta® (eltrombopag)

RYDAPT® (midostaurin)

SANDOSTATIN LAR® DEPOT (octreotide acetate)

Scemblix® (asciminib) Tablets

Tabrecta™ (capmatinib)

Tafinlar® (dabrafenib)

Tasigna® (nilotinib)

Tobradex® (ophthalmic ointment)

Triesence® (triamcinolone acetonide injectable suspension)

Tykerb® (lapatinib)

Vijoice® (alpelisib)

Votrient® (pazopanib)

Xiidra® (lifitegrast ophthalmic solution)

Zarxio™ (filgrastim-sndz)

Ziextenzo® (pegfilgrastim-bmez)‎

ZYKADIA® (ceritinib)

Contact info-Phone: 1-800-277-2254 Fax: 1-855-817-2711

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Novo Nordisk (up to 10 days for processing)

Eligibility

US resident

 

< 400% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<400% FPL)

1

54,360

2

73,240

3

92,120

4

111,000

5

129,880

>5

Add 4,720 for each additional person

Medications are sent to primary care office if approved

Medications eligible for assistance

Fiasp Flextouch (insulin aspart)*

GlucaGen Hypokit

Levemir (insulin detemir) Flextouch*

Novolin N vial (insulin NPH)

Novolin 70/30 (insulin NPH and insulin R mix) vial

Novolin R vial (insulin regular)

Novolog (insulin aspart) FlexPen*

Novlog mix 70/30 (insulin aspart protamine and insulin aspart) FlexPen*

Ozempic (semaglutide) injection*

Rybelsus (semalgutide) tablets

Tresiba (insulin degludec) FlexTouch*

Victoza (liraglutide) pen*

Xultophy (insulin degludec & liraglutide) pen*

*Request Novo Nordisk disposable needles on prescription/application or they will not be sent

Contact info- Phone: 1-866-310-7549 Fax: 1-866-441-4190

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Otsuka Patient Assistance Foundation

Eligibility

US resident

 

< 300-700% FPL

 

Uninsured

 

Household size

Annual household income ($) threshold

All other medications (< 300% FPL)

Jynarque (<700% FPL)

1

40,770

109,860

2

54,930

138,180

3

69,090

166,500

4

83,250

Add 28,320

>5

Call Otsuka 1-855-727-6274

 

Medications available for assistance

Abilify Maintena (aripiprazole) for extended release injectable suspension

Jynarque (tolvaptan) tablets

Rexulti (Brexpiprazole) tablets

Samsca (tolvaptan)

Contact info-Phone: 1-8555-727-6274 Fax: 1-844-727-6274

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Pfizer RxPathways patient assistance program (2-3 weeks for processing)

Eligibility

US resident

 

< 400% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

Non-B medications

<400% FPL

Group B

1

54,360

49,960

2

73,240

67.640

3

92,120

85,320

4

111,000

103,00

5

129,880

120,680

>5

Call Pfizer program 1-866-706-2400

 

Medications eligible for assistance

Insurance Group

Medication name

B

VFEND® (voriconazole)

B

Revatio (sildenafil)

B

RAPAMUNE® (sirolimus)

Non-B medications

AROMASIN® (exemestane) tablets   

ARTHROTEC® (diclofenac sodium/misoprostol) tablets

BeneFIX® Coagulation Factor IX (Recombinant)

BESPONSA™ (inotuzumab ozogamicin, for injection, for intravenous use)

BOSULIF® (bosutinib) tablets

CADUET® (amlodipine besylate/atorvastatin calcium) tablets

CAMPTOSAR® (irinotecan hydrochloride) injection

CAVERJECT® (alprostadil) injection

CAVERJECT® Impulse® (alprostadil) injection

CELEBREX® (celecoxib) capsules

CELONTIN® (methsuximide) capsules, USP

CHANTIX® (varenicline) tablets

CIBINQO™ (abrocitinib) tablets

DAURISMO™ (glasdegib) tablets

DEPO-PROVERA® (medroxyprogesterone acetate injectable suspension)

DEPO®-ESTRADIOL (estradiol cypionate) injection, USP

DETROL® (tolterodine tartrate) tablets

DETROL® LA (tolterodine tartrate) extended-release capsules

DILANTIN® (extended phenytoin sodium) capsules               

DUAVEE™ (conjugated estrogens/bazedoxifene) tablets

ELLENCE® (epirubicin hydrochloride injection)

EMCYT® (estramustine phosphate sodium) capsules

ESTRING® (estradiol vaginal ring)

FELDENE® (piroxicam) capsules

FRAGMIN® (dalteparin sodium) injection

GENOTROPIN® (somatropin) for injection

HEPARIN Sodium Injection, USP

IBRANCE® (palbociclib) capsules

IDAMYCIN PFS® (idarubicin hydrochloride) injection

INFLECTRA® (infliximab-dyyb) for injection

INLYTA® (axitinib) tablets

INSPRA® (eplerenone) tablets

LEVOXYL® (levothyroxine sodium) tablets

LINCOCIN® (lincomycin) injection, USP

LORBRENA® (lorlatinib) tablets

MENEST® (esterified estrogens) tablets, USP

MYCOBUTIN® (rifabutin) capsules, USP                                  

MYLOTARG™ (gemtuzumab ozogamicin) for injection

NICOTROL® (nicotine)

NIVESTYM® (filgrastim-aafi) injection

NORPACE® (disopyramide phosphate)

PREMARIN® (conjugated estrogens) tablets, USP (conjugated estrogens tablets

PREMARIN® (conjugated estrogens) Vaginal Cream (conjugated estrogens) Vaginal Cream

PREMPRO® (conjugated estrogens/medroxyprogesterone acetate) tablets

PREMPHASE® (conjugated estrogens plus medroxyprogesterone acetate) tablets

PREVNAR 13® Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein]

PRISTIQ® (desvenlafaxine) extended-release tablets

RELPAX® (eletriptan hydrobromide) tablets

RETACRIT® (epoetin alfa-epbx) injection

SKELAXIN® (metaxalone) tablets

SOMAVERT® (pegvisomant) for injection

SUTENT® (sunitinib malate) capsules

SYNAREL® (nafarelin acetate) nasal solution

TALZENNA® (talazoparib) capsules

TIKOSYN® (dofetilide) capsules

TORISEL® (temsirolimus) injection

TOVIAZ® (fesoterodine fumarate) extended-release tablets

TRECATOR® (ethionamide) tablets

TRUMENBA® (Meningococcal Group B Vaccine)

TYGACIL® (tigecycline) for injection

VIZIMPRO® (dacomitinib) tablets

VYNDAQEL® (tafamidis meglumine) capsules

XALKORI® (crizotinib) capsules

XANAX® CIV (alprazolam) tablets

XELJANZ® (tofacitinib) tablets

XELJANZ® (tofacitinib) oral solution                                        

XELJANZ® XR (tofacitinib) extended-release tablets

XYNTHA® Antihemophilic Factor (Recombinant)

ZARONTIN® (ethosuximide) ZYVOX® (linezolid)

 

ZYVOX® (linezolid)

Contact info-Phone: 1-866-706-2400 Fax: 1-866-470-1748

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Pfizer Oncology Together

Eligibility

US resident

 

< 500% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<500% FPL)

1

67,950

2

91,550

3

115,150

4

138,750

>5

Click for FPL for household larger than 5 or add 23,600 per each additional person

 

Medications available for assistance

AROMASIN (exemestane)

BOSULIF (bosutinib)

BRAFTOVI (encoarfenib)

DAURISMO (glasdegib)

EMCYT (estramustine)

IBRANCE (Palbociclib)

INLYTA (axitinib)

LORBRENA (lorlatinib)

MEKTOVI (bibimetinib)

SUTENT (sunitinib)

TALZENNA (talazoparib)

VIZIMPRO (dacaomitinib)

XALKORI (crizotinib)

BESPONSA (inotuzumab)

CAMPTOSAR (irinotecan)

ELLENCE (epirubicin)

IDAMYCIN (idarubicin)

MYLOTARG (gemtuzumab)

TORISEL (temsirolimus)

NIVESTYM (filgrastim-aafi)

NYVEPRIA (pegfilgrastim-apgf)

RETACRIT (epoetin alfa-epbx)

RUXIENCE (rituximab-pvvr)

TRAZIMERA (trastuzumab-qyyp)

ZIRABEV (bevacizumab-bvzr)

Contact info-Phone: 1-877-744-5675 Fax:  1-877-736-6506

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Radius Assist

Eligibility

US resident

 

< 300% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<300% FPL)

1

40,770

2

54,930

3

69,090

4

83,250

>5

Contact Radius program at 1-866-896-5674

 

Medication eligible for assistance

TYMLOS (abaloparatide) injection

Contact info-Phone: 1-866-896-5674 Fax: 1-800-910-4610

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Roche through Genentech

Program eligibility

1.     Uninsured making <$150,000

2.     Insured patients as follows:

Household size

Annual household income ($) threshold

1

<75,000

2

<100,000

3

<125,00

4

<150,000

>5

Add 25,000 for each additional person

 

Medications eligible for assistance

Actemra (tocilizumab)1

Activase (alteplase)

Alcensa (alectinib)

Avastin (bevacizumab)

Cathflo Activase (alteplase)

Cotellic (cobimetinib)

Enspryng (satralizumab-mwge)

Erivedge (vismodegib)

Esbriet (pirfenidone)

Evrysdi (risdiplam)

Gavreto (pralsetinib)

Gazyva (Obinutuzumab)

Hemlibra (emcizumab-kxwh)

Herceptin (trastuzumab)

Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)

Kadcyla (ado-trastuzumab emtansine)

Lucentis (ranibizumab injection)

Ocrevus (orelizumab)

Pegasys (peginterferon alfa-2a)

Perjeta (pertuzumab)

Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf)

Polivy (polatuzumab vedotin-piiq)

Pulmozyme (dornade alfa) inhalation solution

Rituxan (rituximab) for rheumatoid arthritis1

Rituxan (rituximab) for oncology

Rituxan (rituximab) for granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) or pemphigus vulgaris (PV)

Rituxan hycela (rituximab/hyaluronidase human)

Rozlytrek (entrectinib)

Susvimo (ranibizumab)

Tecentriq (atezolizumab)

TNKase (Tenecteplase)

Vabysmo (faricimab-svoa)

Venclexta (venetoclax tablets)

Xeloda (capecitabine)

Xolair (omalizumab)

Zelboraf (vemurafenib)

1. $5.00 copay, up to $15,000 in assistance annually for drug costs and up to $2,000 in infusion assistance

                   **Additional programs for Cellcept, Evrysdi, Valcyte, Fuzeon, Nutropin available***

Contact info-Phone:(888)-941-3331 Fax: (833)-999-4363

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Sanofi

Sanofi patient connection program (5-7 days medication sent directly to primary care provider office)

Eligibility

US resident

 

< 400% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<400% FPL)

1

54,360

2

73,240

3

92,120

4

111,000

5

129,880

>5

Add 4,720 for each additional person

 

Medications eligible for assistance

Adacel® (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed)

Admelog® (insulin lispro injection) 100 Units/mL

Apidra® (insulin glulisine injection) 100 Units/mL

Imogam® Rabies-HT Immune Globulin, [Human] USP, Heat Treated

Imovax® Rabies Vaccine [Human Diploid Cell]

Lantus® (insulin glargine injection) 100 Units/mL

Lovenox® (enoxaparin sodium injection)1

MenQuadfi® (Meningococcal [Groups A, C, Y, W] Conjugate Vaccine)

Mozobil® (plerixafor injection)1

Multaq® (dronedarone) Tablets

Pentacel® Diptheria and Tetanus Toxoids and Acellular Pertussis Adsorbed, Inactivated Poliovirus and Haemophilus b Conjugate (Tetanus Toxoid Conjugate) Vaccine

Priftin® (rifapentine) Tablets

Soliqua® 100/33 (insulin glargine & lixisenatide) injection 100 Units/mL and 33 mcg/mL

Tenivac® (tetanus and diphtheria toxoids adsorbed

Thymoglobulin® [Anti-Thymocyte Globulin (Rabbit)1

Toujeo® (insulin glargine injection) 300 Units/mL (1.5 mL or 3.0 mL pens)2

1. if applying for Drug Replacement (Lovenox®, Mozobil®, and Thymoglobulin®), a copy of the claim, denial, flow sheet(s) and drug dispensing log (with patient name, date of service, product NDC/Lot #, total dosage) must be submitted

2. Regular SoloStar® is packaged as 3 pens per pack 450 units/pen; dials up to 80 units per single injection. Max SoloStar® is packaged as 2 pens per pack 900 units/pen; dials up to 160 units per single injection; Max pen dials in 2-unit increments

Contact info-Phone: 1-888-847-4877 Fax: 1-888-847-4797

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Sunovion Prescription Assistance Program

Eligibility

US resident

 

< 300% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<300% FPL)

1

40,770

2

54,930

3

69,090

4

83,250

 

Medications eligible for assistance

Aptiom® (eslicarbazepine acetate)

Kynmobi™ (apomorphine hydrochloride)

Latuda (lurasidone)

Contact info-Phone: 877-850-0819 Fax: 877-850-0821

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TAKEDA: Help at Hand

Eligibility

US resident

 

< 500% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<500% FPL)

1

67,950

2

91,550

3

115,150

4

138,750

>5

Click for FPL for household larger than 5 or add 23,600 per each additional person

 

Medications eligible for assistance

Amitiza (lubiprostone)

Carbatrol (carbamazepine extended-release) capsules

Colcrys (colchicine) tablets

Dexilant (dexlansoprazole) DR capsules

Fosrenol (lanthanum carbonate)

Intuniv (guanfacine) ER tablets

Kazano (alogliptin/metformin) tablets

Lialda (mesalamine) DR tablets

Motegrity (prucalopride) tablets

Mydayis (amphetamine) ER capsules

Nesina (alogliptin) tablets

Oseni (alogliptin/pioglitazone) tablets

Pentasa (mesalamine) ER capsules

Prevacid (lansoprazole) ODT tablets

Rozerem (ramelteon) tablets

Trintellix (vortioxetine tablets)

Vyvanse (lisdexamfetamine) capsules and tablets

Contact info-Phone: 1-800-830-9159  Fax: 1-800-497-0928

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TEVA Cares Foundation

Eligibility

US resident

 

<300 - 500% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

Non-oncology medications

<300% FPL

Oncology medications

<500% FPL

1

40,770

67,950

2

54,930

91,550

3

69,090

115,150

4

83,250

138,750

5

97,410

162,350

>5

Click for FPL thresholds

 

Medications eligible for assistance

BENDEKA (bendamustine)

Clozapine

Cyclosporine capsules modified

Cyclosporine oral solution modified

GABITRIL (tigabine hydrochloride) tablets

GALZIN (zinc acetate) capsules

GRANIX (tbo-filgrastim) injection

HERZUMA (trastuzumab-pkrb) injection

NUVIGIL (armodafinil) tablets [C-IV]

ProAir RespiClick (albuterol sulfate) inhalation aerosol

ProAir HFA (albuterol sulfate) inhalation aerosol

Proglycem (diazoxide) oral suspension

QNASL (beclomethasone) nasal aerosol

QVAR RediHaler (beclomethasone dipropionate HFA) inhalation aerosol

SYNRIBO (omacetaxine) for injection

TREANDA (bedamustine) for injection

TRISENOX (arsenice trioxide) injection

TRUXIMA (rituximab-abbs) injection

Contact info-Phone: 877-237-4881 Fax: 877-438-4404

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Tolmar Total solutions

Eligibility

US resident

 

< 500% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<500% FPL)

1

67,950

2

91,550

3

115,150

4

138,750

>5

Click for FPL for household larger than 5 or add 23,600 per each additional person

 

Medication eligible for assistance

Eligard (leuprolide)

Contact info-Phone: 1-844-TOLMAR1 Fax: 1-844-TOLMAR2

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Veltassa Konnect

Eligibility

US resident

 

< 500% FPL

 

Uninsured/Medicare

 

Household size

Annual household income ($) threshold

(<500% FPL)

1

67,950

2

91,550

3

115,150

4

138,750

>5

Click for FPL for household larger than 5 or add 23,600 per each additional person

 

Medication eligible for assistance

Veltassa (patiromer)

Contact info-Phone: 1-8888-623-7092 Fax: 1-888-623-7092

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PAPs by Disease State/Condition

ANTI-MIGRAINE

Medications available for assistance

Aimovig (Erenumab)

Botox (Onabotulinumtoxina)

Emgality® (Galcanezumab-Gnlm) Injection

Imitrex (Sumatriptan Nasal Spray)

QULIPTA (Atogepant) Tablets

Relpax (Eletriptan)

Relpax® (Eletriptan Hydrobromide) Tablets

Reyvow® (Lasmiditan) Tablets C-V

Ubrelvy (Ubrogepant) Tablets

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Antithrombotics

Medication class

Medication name

Anticoagulant

Arixtra (Fondaparinux)

Eliquis® (Apixaban)

Fragmin® (Dalteparin Sodium) Injection

Heparin Sodium Injection, Usp

Lovenox® (Enoxaparin Sodium Injection)

Pradaxa (Dabigatran)

Xarelto (Rivaroxaban) Tablets Or Oral Solution

Antiplatelet

Brilinta (Ticagrelor)

Clotting factor

Benefix® Coagulation Factor Ix (Recombinant)

Thrombolytic

Activase (Alteplase)

Cathflo Activase (Alteplase)

TNKase (Tenecteplase)

 

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AUTOIMMUNE DISORDERS

Medications available for assistance

Disease state

Actemra (Tocilizumab)

Rheumatoid arthritis

Adakveo® (Crizanlizumab-Tmca)

Sickle cell

Avsola (Infliximab-Axxq)

Plaque psoriasis, Crohn’s, Ulcerative colitis, Rheumatoid arthritis

Benlysta  (Belimumab)

Lupus nephritis

Canasa (Mesalamine) Suppository

Crohn’s, Ulcerative colitis

Cibinqo™ (Abrocitinib) Tablets

Atopic dermatitis

Cosentyx® (Secukinumab)

Plaque psoriasis, Psoriatic arthritis, Ankylosing spondylitis

CREON (Pancrelipase) Delayed-Release Capsules

Pancreatic insufficiency

Cyclosporine Capsules Modified

Transplant, Rheumatoid arthritis, Psoriasis

Cyclosporine Oral Solution Modified

Transplant, Rheumatoid arthritis, Psoriasis

Cystagon (Cysteamine) Capsules

Nephropathic cystinosis

Delzicol (Mesalamine Dr) Capsules

Crohn’s, Ulcerative colitis

Depen (Penicillamine) Tablets

Wilson's disease, cystinuria

Dipentum (Olsalazine) Capsule

Crohn’s, Ulcerative colitis

Enbrel (Etanercept)

Plaque psoriasis, Psoriatic arthritis, Ankylosing spondylitis

Enspryng (Satralizumab-Mwge)

Neuromyelitis optica spectrum disorder

Esbriet (Pirfenidone)

Idiopathic pulmonary fibrosis

Evrysdi (Risdiplam)

Spinal muscular atrophy

Extavia® (Interferon Beta-1B)

Multiple sclerosis, relapsing

Gengraf Capsules (Cyclosporine, Usp [Modified])

Transplant, Rheumatoid arthritis, Psoriasis

Genotropin® (Somatropin) For Injection

Growth hormone deficiency or failure (pediatrics)

Gilenya® (Fingolimod)

Multiple sclerosis, relapsing

Glatiramer Acetate

Multiple sclerosis, relapsing

Hemlibra (Emcizumab-Kxwh)

Hemophilia A, prophylaxis

Humatrope® (Somatropin) For Injection

Growth hormone deficiency or failure (pediatrics)

Humira (Adalimumab)

Plaque psoriasis, Crohn’s, Ulcerative colitis, Rheumatoid arthritis

ILARIS® (Canakinumab)

Adult onset Still's disease, Periodic fever syndromes

Inflectra® (Infliximab-Dyyb) For Injection

Plaque psoriasis, Crohn’s, Ulcerative colitis, Rheumatoid arthritis

Lialda (mesalamine) DR tablets

Crohn’s, Ulcerative colitis

Mavyret (Glecaprevir/Pibrentasvir)

Chronic hepatitis C

Mayzent® (Siponimod)

Multiple sclerosis

Mozobil® (Plerixafor Injection)

Peripheral stem cell mobilization

Nplate (Romiplostim)

Immune thrombocytopenia

Nulojix® (Belatacept))

Kidney transplant (de novo use)

Ocrevus (Orelizumab)

Multiple sclerosis, relapsing or primary progressive

Ofev (Nintedanib)

Idiopathic pulmonary fibrosis

Olumiant® (Baricitinib) Tablets

Rheumatoid arthritis

Omnitrope® Somatropin (Rdna Origin)

Growth hormone deficiency or failure (pediatrics)

Orencia® (Abatacept)

Graft vs host disease, Psoriatic arthritis, Rheumatoid arthritis

Otezla (Apremilast)

Psoriasis, Psoriatic arthritis, Bechet disease

Pegasys (Peginterferon Alfa-2A)

Chronic hepatitis B

Pentasa (mesalamine) ER capsules

Crohn’s, Ulcerative colitis

Ponvory (Ponesimod)

Multiple sclerosis, relapsing

Promacta® (Eltrombopag)

Immune thrombocytopenia

Rapamune® (Sirolimus)

Renal transplant, lymphangioleiomyomatosis

Reblozyl® (Luspatercept-Aamt)

Anemia due to myelodysplastic syndromes

Remicade (Infliximab) IV Infusion

Plaque psoriasis, Crohn’s, Ulcerative colitis, Rheumatoid arthritis

Rinvoq (Upadacitinib)

Psoriatic arthritis, Atopic dermatitis, Ulcerative colitis, Rheumatoid arthritis

Rituxan (Rituximab) For Rheumatoid Arthritis

Rheumatoid arthritis

Rowasa (Mesalamine) Rectal Suspension

Crohn’s, Ulcerative colitis

Saphnelo (Anifrolumab-Fnia)

Systemic lupus erythematosus, moderate to severe

Sf Rowasa (Mesalamine) Rectal Suspension

Crohn’s, Ulcerative colitis

Simponi (Golimumab) Injection

Psoriatic arthritis, Ankylosing spondylitis, Ulcerative colitis, Rheumatoid arthritis

Skyrizi (Risankizumab-Rzaa)

Plaque psoriasis, Psoriatic arthritis

Somavert® (Pegvisomant) For Injection

Acromegaly

Stelara (Ustekinumab) For Subcutaneous Or Iv Use

Crohn’s, Plaque psoriasis, Psoriatic arthritis, Ulcerative colitis

Taltz® (Ixekizumab) Injection

Ankylosing spondylitis, Plaque psoriasis, Psoriatic arthritis

Tremfya (Guselkumab) For Subcutaneous Use

Plaque psoriasis, Psoriatic arthritis

Truxima (Rituximab-Abbs) Injection

Rheumatoid arthritis

Viokace (Pancrelipase) Tablets

Pancreatic insufficiency

Vyndaqel® (Tafamidis Meglumine) Capsules

Amyloid cardiomyopathy

Xeljanz® (Tofacitinib) Oral Solution

Ankylosing spondylitis, Plaque psoriasis, Psoriatic arthritis, Rheumatoid arthritis, Ulcerative colitis

Xeljanz® (Tofacitinib) Tablets

Xeljanz® Xr (Tofacitinib) Extended-Release Tablets

Xyntha® Antihemophilic Factor (Recombinant)

Hemophilia A

Zenpep (Pancrelipase) Delayed Release Capsule

Pancreatic insufficiency

Zeposia® (Ozanimod)

Multiple sclerosis, relapsing

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CARDIOVASCULAR

Medications available for assistance

Bystolic (Nebivolol) Tablets

Caduet (Amlodipine/Atorvastatin)

Corlanor (Ivabradine)

Entresto™ (Sacubitril/Valsartan)

Farxiga (Dapagliflozin)

Inspra (Eplerenone)

Jardiance (Empagliflozin)

Leqvio® (Inclisiran)

Lokelma (Sodium Zirconium Cyclosilicate)

Multaq® (Dronedarone) Tablets

Norpace® (Disopyramide Phosphate)

Opsumit (Macitentan) Tablets

Praluent (alirocumab)

Repatha (Evolocumab)

Tikosyn® (Dofetilide) Capsules

Tracleer (Bosentan)

Uptravi (Selexipag)

Veletri (Epoprostenol)

Ventavis (Iloprostol)

Verquvo™ (Vericiguat) 2.5 Mg, 5 Mg, 10 Mg Tablets

Veltassa (patiromer)

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Diabetes

Medication class

Medication name

DPP4 inhibitor

Januvia® (Sitagliptin) Tablets

Nesina (alogliptin) tablets

Onglyza (Saxagliptin)

Tradjenta (Linagliptin)

GLP-1

Bydureon (Exenatide Extended Release)

Byetta (Exenatide)

Ozempic (Semaglutide) Injection

Rybelsus (Semalgutide) Tablets

Trulicity® (Dulaglutide) Injection

Victoza (Liraglutide) Pen

GLP-1 insulin combo

Soliqua® 100/33 (Insulin Glargine & Lixisenatide) Injection 100 Units/Ml And 33 Mcg/mL

Xultophy (Insulin Degludec & Liraglutide) Pen

Insulin

Rapid acting

Admelog® (Insulin Lispro Injection) 100 Units/mL

Apidra® (Insulin Glulisine Injection) 100 Units/mL

Fiasp Flextouch (Insulin Aspart)

Humalog® U-100 (Insulin Lispro Injection)

Humalog® U-200 (Insulin Lispro Injection)

Lyumjev™ (Insulin Lispro-Aabc) Injection

Novolog (Insulin Aspart) Flexpen

Short acting

Humulin® R (Insulin Human Injection)

Humulin® R U-500 (Insulin Human Injection)

Novolin R Vial (Insulin Regular)

Intermediate acting

Humulin® N (Isophane Insulin Human Suspension)

Novolin N Vial (Insulin Nph)

Long acting

Basaglar® (Insulin Glargine Injection)

Lantus® (Insulin Glargine Injection) 100 Units/mL

Levemir (Insulin Detemir) Flextouch

Semglee (Insulin Glargine)

Toujeo® (insulin glargine injection) 300 Units/mL (1.5 mL or 3.0 mL pens)

Tresiba (Insulin Degludec) Flextouch

Mixed insulin

Rapid/Intermediate

Humalog® Mix50/50™ (Insulin Lispro Protamine And Insulin Lispro Injectable Suspension)

Humalog® Mix75/25™ (Insulin Lispro Protamine And Insulin Lispro Injectable Suspension)

Novlog Mix 70/30 (Insulin Aspart Protamine And Insulin Aspart) Flexpen

Regular/Intermediate

Humulin® 70/30 (Human Insulin Isophane Suspension And Human Insulin Injection)

Novolin 70/30 (Insulin Nph And Insulin R Mix) Vial

SGLT-2 inhibitor

Farxiga (Dapagliflozin)

Invokana (Canagliflozin)

Jardiance (Empagliflozin)

Combination oral

SGLT2/metformin

Glyxambi (Empagliflozin/Metformin)

Invokamet (Canagliflozin/Metformin)

Invokamet Xr (Canagliflozin/Metformin Xr)

Synjardy & Synjardy Xr (Empagliflozin/Metformin)

Xigduo Xr (Dapagliflozin/Metformin Er)

DPP4/metformin

Janumet® (Sitagliptin And Metformin Hci) Tablets

Janumet® Xr (Sitagliptin And Metformin Hci Extended-Release) Tablets 

Jentadueto & Jentadueto Xr (Linagliptin/Metformin)          

Kazano (alogliptin/metformin) tablets

Kombiglyze Er (Saxagliptin/Metformin Er)

DPP4/SGLT2

Qtern (Dapagliflozin/Saxagliptin)

DPP4/metformin/SGLT2

Trijardy Xr (Empagliflozin/Linagliptin/Metformin)

DPP4/TZD

Oseni (alogliptin/pioglitazone) tablets

Other

Symlin (Pramlintide)

Hypoglycemia management

Baqsimi® (Glucagon) Nasal Powder

 

Glucagon™ (Glucagon For Injection)

 

Glucagen Hypokit      

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INFECTIOUS DISEASE (HIV & Acute)

Medications available for assistance

ACUTE

Avycaz (Avibactam/Ceftazidime)

Boostrix (Tdap Vaccine)

Cancidas® (Caspofungin Acetate) For Injection

Coartem® (Artemether And Lumefantrine)

Dalvance (Dalbavancin) Lyophilizate

Dificid® (Fidaxomicin) For Oral Suspension 40 Mg/mL

Dificid® (Fidaxomicin) Tablets

Engerix-B (Hepatitis B Vaccine)

Extavia® (Interferon Beta-1B)

Gardasil®9 (Human Papillomavirus 9-Valent Vaccine, Recombinant) 

Imogam® Rabies-Ht Immune Globulin, [Human] Usp, Heat Treated

Imovax® Rabies Vaccine [Human Diploid Cell]

Lincocin® (Lincomycin) Injection, Usp

Malarone (Atovaquone And Proguanil)

Mavyret (Glecaprevir/Pibrentasvir)

Menquadfi® (Meningococcal [Groups A, C, Y, W] Conjugate Vaccine)

Mepron (Atovaquone Suspension)

M-M-R® Ii (Measles, Mumps, And Rubella Virus Vaccine Live) 

Monurol (Fosfomycin Tromethamine) Oral Granules

Mycobutin® (Rifabutin) Capsules, Usp

Noxafil® (Posaconazole) Delayed-Release Tablets 100 Mg

Noxafil® (Posaconazole) Oral Suspension, 40 Mg/Ml

Pegasys (Peginterferon Alfa-2A)

Pentacel® Diptheria And Tetanus Toxoids And Acellular Pertussis Adsorbed, Inactivated Poliovirus And Haemophilus B Conjugate (Tetanus Toxoid Conjugate) Vaccine

Pretomanid Tablet

Prevnar 13® Pneumococcal 13-Valent Conjugate Vaccine [Diphtheria Crm197 Protein]

Prevymis™ (Letermovir) 240 Mg Tablets

Priftin® (Rifapentine) Tablets

Pylera (Bismuth Subcitrate Potassium, Metronidazole, And Tetracycline) Capsules

Recarbrio™ (Imipenem, Cilastatin, And Relebactam) For Injection, For Intravenous Use

Recombivax Hb® [Hepatitis B Vaccine (Recombinant)] 

Relenza (Zanamivir Inhalation Powder)

Shingrix  (Zoster Vaccine)

Sirturo (Bedaquiline) Tablets

Sporanox (Itraconazole) Capsules And Oral Solution

Stromectol® (Ivermectin) Tablets

Teflaro (Ceftaroline Fosamil) Powder For Injection

Tenivac® (Tetanus And Diphtheria Toxoids Adsorbed

Tobi (Tobramycin) Ampules Or Podhalers

Trumenba® (Meningococcal Group B Vaccine)

Tygacil® (Tigecycline) For Injection

Vaqta® (Hepatitis A Vaccine, Inactivated) 

Varivax® (Varicella Virus Vaccine Live) 

Vaxneuvance™ (Pneumococcal 15-Valent Conjugate Vaccine) 

Vfend® (Voriconazole)

Zepatier® (Elbasvir And Grazoprevir) 

Zerbaxa™ (Ceftolozane And Tazobactam) For Injection For Intravenous Use 

Zyvox® (Linezolid)

HIV

Cimduo (Lamivudine/Tenofovir Disoproxil Fumarate) Tablet

Delstrigo™ (Doravirine, Lamivudine, And Tenofovir Disoproxil Fumarate) Tablets, For Oral Use

Edurant (Rilpivirine) Tablets

Epivir-Hbv (Lamivudine Solution Or Tablets)

Intelence (Etravirine) Tablets

Isentress® (Raltegravir) 400 Mg Film-Coated And 25 Mg And 100 Mg Chewable Tablets

Isentress® Hd (Raltegravir) 600 Mg Tablets

Isentress® Os (Raltegravir) 100 Mg Granules For Suspension            

Kaletra (Lopinavir/Ritonavir)

Norvir (Ritonavir) Tablets And Oral Solution

Pifeltro™ (Doravirine) Tablets, For Oral Use

Pneumovax®23 (Pneumococcal Vaccine Polyvalent) 

Prezcobix (Darunavir/Cobicistat)

Prezista (Darunavir)

Symtuza (Darunavir, Cobicistat, Emtricitabine, Tenofovir Alafenamide) Tablets

Viramune Xr (Nevirapine)

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Inhalers

Medication class

Medication name

ICS+

Arnuity Ellipta (Fluticasone)

Flovent (Diskus Or Hfa) (Fluticasone)

Pulmicort Flexhaler (Budesonide)

Qvar Redihaler (Beclomethasone Dipropionate Hfa) Inhalation Aerosol

ICS (nasal)

Beconase Aq  (Beclomethasone Dipropionate Nasal Spray)

Dymista (Azelastine/Fluticasone) Nasal Spray

Qnasl (Beclomethasone) Nasal Aerosol

LAMA/LABA

Anoro Ellipta (Umeclidinium/Vilanterol)

Bevespi Aerosphere (Glycopyrrolate/Formoterol)

Stiolto Respimat (Tiotropium/Olodaterol)

LABA/ICS

Advair (Diskus Or Hfa) (Fluticasone/Salmeterol)

Breo Ellipta (Fluticasone/Vilanterol) 

Symbicort (Budesonide/Formoterol)

Wixela (Fluticasone/Salmeterol)

LABA*

Perforomist (Formoterol Fumarate) Inhalation Solution

Serevent (Diskus) (Salmeterol)

Striverdi Respimat (Olodaterol)

LAMA

Incruse Ellipta (Umeclidinium)

Spiriva Handihaler Or Respimat (Tiotropium)

Yupelri (Revefenacin)

LAMA/LABA/ICS

Breztri Aerosphere (Budesonide/Glycopyrrolate/Formoterol)

SABA/SAMA

Combivent Respimat (Ipratropium/Albuterol)

SABA

Proair Hfa (Albuterol Sulfate) Inhalation Aerosol

Proair Respiclick (Albuterol Sulfate) Inhalation Aerosol

SAMA

Atrovent Hfa (Ipratropium)

Other

Aerochamber Plus Flow-Vu

Daliresp (Roflumilast)

Pulmozyme (Dornase Alfa) Inhalation Solution

Xolair (Omalizumab)

Fasenra (Benralizumab)

Fasenra Pen (Benralizumab)

Nucala (Mepolizumab)

+ Not to be prescribed as monotherapy in COPD

* Not to be prescribed as monotherapy in Asthma

ICS=inhaled corticosteroid, LABA=long acting beta agonist, LAMA=long acting muscarinic antagonist, SABA=short acting beta agonist, SAMA=short acting muscarinic antagonist

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NEUROLOGY & PSYCHIATRY

Medications available for assistance

Aptiom® (eslicarbazepine acetate)

Belsomra® (Suvorexant) C-IV

Carbatrol (carbamazepine extended-release) capsules

Chantix® (Varenicline) Tablets

Celontin® (Methsuximide) Capsules, Usp

Clozapine

Depakote (Divalproex Sodium)

Dilantin® (Extended Phenytoin Sodium) Capsules

Felbatol (Felbamate)

Fetzima (Levomilnacipran) Extended Release Capsules And Titration Pack

Gabitril (Tigabine Hydrochloride) Tablets

Haldol Decanoate (Haloperidol) Im Injection Only

Intuniv (guanfacine) ER tablets

Lamictal (Lamotrigine Chewable Or Orally Disintegrating Tablets)

Lamictal ODT (Lamotrigine Patient Titration Kits)

Lamictal Xr (Lamotrigine Er Or Patient Titration Kit)

Lexapro (Escitalopram)

Mydayis (amphetamine) ER capsules

NUPLAZID (pimavanserin)

Nicotrol® (Nicotine)

Pristiq® (Desvenlafaxine) Extended-Release Tablets

Prozac® (Fluoxetine Capsules)

Rexulti (Brexpiprazole) Tablets

Risperdal Consta (Risperidone) Long-Acting Injection

Rozerem (ramelteon) tablets

Saphris (Asenapine Maleate) Sublingual Tablet

Savella (Milnacipran) Tablets

Strattera® (Atomoxetine) Capsules

Symbyax® (Olanzapine And Fluoxetine) Capsules

Trintellix (vortioxetine tablets)

Viibryd (Vilazodone)

Vraylar (Cariprazine) Capsules

Vyvanse (lisdexamfetamine) capsules and tablets

Xanax® CIV (Alprazolam) Tablets

Zarontin® (Ethosuximide)

Zyprexa® (Olanzapine) Tablet

Zyprexa® Zydis® (Olanzapine) Tablet

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ONCOLOGY

Medications available for assistance

Abraxane® (Paclitaxel Protein-Bound Particles For Injectable Suspension (Albumin-Bound))

Afinitor Disperz® (Everolimus Suspension)

Afinitor® (Everolimus)

Alcensa (Alectinib)

Alimta® (Pemetrexed For Injection)

Aranesp (Darbepoetin Alfa)

Aromasin® (Exemestane) Tablets

Avastin (Bevacizumab)

Balversa (Erdafitinib) Tablets

Bendeka (Bendamustine)

BESPONSA (inotuzumab)

Blenrep (Belantamab)

Blincyto (Blinatumomab)

BOSULIF (bosutinib)

BRAFTOVI (encoarfenib)

Calquence (Acalabrutinib)

CAMPTOSAR (irinotecan)

Cotellic (Cobimetinib)

Cyramza® (Ramucirumab) Injection

Darzalex (Daratumumab) Injection For Iv Infusion

Darzalex Faspro (Daraumumab And Hyaluronidase-Fihj) Injection For Subcutaneous Use

DAURISMO (glasdegib)

Eligard (leuprolide)

ELLENCE (epirubicin)

EMCYT (estramustine)

Emend® (Aprepitant) 80 Mg, 125 Mg Capsules

Emend® (Aprepitant) For Oral Suspension 125 Mg

Emend® (Fosaprepitant Dimeglumine) For Injection 150 Mg

Empliciti® (Elotuzumab)

Epogen (Epoetin Alfa)

Erbitux® (Cetuximab) Injection

Erivedge (Vismodegib)

Erleada (Apalutamide) Tablets

Falsodex (Fulvestrant)

Fulphila (Pegfilgastrim-Jmdb)

Fulvestrant Injection, For Intramuscular Use

FYARRO (sirolimus albumin-bound) for injection

Gavreto (Pralsetinib)

Gazyva (Obinutuzumab)

Giltorif (Afatinib)

Granix (Tbo-Filgrastim) Injection

Herceptin (Trastuzumab)

Herceptin Hylecta (Trastuzumab And Hyaluronidase-Oysk)

Herzuma (Trastuzumab-Pkrb) Injection

Hycamtin® (Topotecan Hydrochloride) For Injection

Hycamtin® (Topotecan) Capsules

IBRANCE (Palbociclib)

IDAMYCIN (idarubicin)

IDHIFA® (Enasidenib)

Imbruvica (Ibrutinib) Capsules/Tablets

Imbruvica (Ibrutinib)

Imfinzi (Durvalumab)

Imlygic (Talimogene)

INLYTA (axitinib)

Inrebic® (Fedratinib)

Istodax® (Romidepsin)

Jemperli (Dostarlimab)

Kadcyla (Ado-Trastuzumab Emtansine)

Kanjinti (Trastuzumab-Anns)

Kesimpta® (Ofatumumab)

Keytruda® (Pembrolizumab) Injection [Liquid Formulation] 100 Mg

Kisqali® Femara® Co-Pack (Ribociclib And Letrozole) Tablets

Kisqali® (Ribociclib)

Koselugo (Selumetinib)

Kyprolis (Carilzomib)

Levoleucovorin Injection

LORBRENA (lorlatinib)

Lucentis (Ranibizumab Injection)

Lumakras (Sotorasib)

Lumoxiti (Moxetumomab Pasudotox-Tdffk)

Lupron Depot (Leuprolide Acetate For Depot Suspension)

Lupron Depot-Ped (Leuprolide Acetate For Depot Suspension)

Lutathera® (Lutetium Lu 177 Dotatate)

Lynparza (Olaparib)

Mekinist® (Trametinib)

MEKTOVI (bibimetinib)

Mvasi (Bevacizumab-Awwb)

MYLOTARG (gemtuzumab)

Neulasta (Pegfilgrastim)

Neupogen (Filgrastim)

NIVESTYM (filgrastim-aafi)

NYVEPRIA (pegfilgrastim-apgf)

Ogivri* (Trastuzumab-Dkst)

Onureg® (Azactidine Tablets)

Opdivo® (Nivolumab)

Opdualag™ (Nivolumab And Relatlimab – Rmbw)

Perjeta (Pertuzumab)

Phesgo (Pertuzumab, Trastuzumab, And Hyaluronidase-Zzxf)

Piqray® (Alpelisib)

Pluvicto® (177Lu-Psma-617)

Polivy (Polatuzumab Vedotin-Piiq)

Pomalyst® (Pomalidomide)

Portrazza® (Necitumumab) Injection

Procrit (Epoetin Alfa)

RETACRIT (epoetin alfa-epbx)

Retevmo™ (Selpercatinib) Capsules

Revlimid® (Lenalidomide)

Riabni (Rituximab-Arrx)

Rituxan (Rituximab) For Granulomatosis With Polyangiitis (Gpa), Microscopic Polyangiitis (Mpa) Or Pemphigus Vulgaris (Pv)

Rituxan (Rituximab) For Oncology

Rituxan Hycela (Rituximab/Hyaluronidase Human)

Rozlytrek (Entrectinib)

RUXIENCE (rituximab-pvvr)

Rybrevant (Amivantamab-Vmjw)

Rydapt® (Midostaurin)

Scemblix® (Asciminib) Tablets

Sprycel® (Dasatinib)

SUTENT (sunitinib)

Synribo (Omacetaxine) For Injection

Tabrecta™ (Capmatinib)

Tafinlar® (Dabrafenib)

Tagrisso (Osimertinib)

TALZENNA (talazoparib)

Tasigna® (Nilotinib)

Tecentriq (Atezolizumab)

Thalomid® (Thalidomide)

TORISEL (temsirolimus)

TRAZIMERA (trastuzumab-qyyp)

Treanda (Bedamustine) For Injection

Trisenox (Arsenice Trioxide) Injection

Tykerb® (Lapatinib)

Vectibix (Panitumumab)

Venclexta (Venetoclax Tablets)

Venclexta (Venetoclax) Tablets

Verzenio® (Abemaciclib) Tablets

Vidaza® (Azacitidine For Injection)

Vijoice® (Alpelisib)

VIZIMPRO (dacaomitinib)

Votrient® (Pazopanib)

Welireg™ (Belzutifan) 40 Mg Tablets

XALKORI (crizotinib)

Xeloda (Capecitabine)

Yervoy® (Ipilimumab)

Yondelis (Trabectedin) For Iv Infusion

Zarxio™ (Filgrastim-Sndz)

Zelboraf (Vemurafenib)

Ziextenzo® (Pegfilgrastim-Bmez)‎

ZIRABEV (bevacizumab-bvzr)

Zolinza® (Vorinostat) 100 Mg Capsules

Zykadia® (Ceritinib)

Zynlonta (loncastuximab tesirine)

Zytiga (Abiraterone) Tablets

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Produced by:

Kyle Ames, PharmD, BCPS

Transitions of care pharmacist liaison

Last revised: 9/12/2022

Copyright 6/3/2022